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Heart failure is not what it seems

The very mention of the term heart failure sounds like a death sentence but this is a misconception. Although it is true that patients do get very ill and die with this disease, treatment has moved on remarkably in the last few years with huge improvements in outlook for patients.

Heart failure is a syndrome where the heart does not pump adequately for the needs for the body. This may be because the heart muscle is weakened or because the heart does not relax well enough. It can also happen if the valves of the heart are obstructed or leak.

The most common symptom is unexpected breathlessness for the level of exercise performed. Anyone can become breathless (imagine walking up 4 flights of stairs – you would expect to be breathing harder but it wouldn’t worry you). On the other hand if you were just sitting in a chair and you felt like you had walked up 4 flights, then that is unexpected breathlessness.

Other symptoms are swelling of the ankles or legs, undue tiredness or palpitation – a feeling of the heart beating harder than normal or fluttering.

Fortunately, the mainstay of treatment is medication, started at a low dose and then gradually increased. The big strides forward that we have taken have occurred because we realise that patients need 4 classes of drugs to treat heart failure.

ACE inhibitors and Entresto relax the blood vessels and block the production of a hormone (angiotensin 2) that is detrimental to heart failure patients. Beta blockers slow down the heart and make it more efficient. They also reduce the risk of abnormal rhythms of the heart. Aldosterone antagonists block another nasty hormone (aldosterone) that causes water retention. The gliflozin tablets are the most interesting of all. These diabetic medications cause glucose to come out in the urine. Quite how they improve prognosis in heart failure is not settled yet, but they have a powerful beneficial effect. All these medications have been proven to reduce mortality and or admission to hospital.

In addition to these medications, diuretics are really important to control fluid overload and improve symptoms.

Heart failure treatments do not stop there. We have defibrillators to reduce the risk of sudden death, complex pacemakers that allow the heart to pump more strongly. New drugs are being developed (like vericiguat which seems to improve the pumping action too) but the most important thing is to make sure the right things are done at the right time for each patient.

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